When bones turn soft

Osteoporosis, a condition characterized by low bone mineral density and weakened bone structure, is a significant public health concern, affecting millions of people worldwide.

Osteoporosis is effectively the loss of calcium from bones, either due to impaired absorption of calcium or due to excessive loss of calcium from bones.

While osteoporosis can affect anyone, it is particularly prevalent in older women, with many of postmenopausal white women experiencing an osteoporotic-related fracture in their lifetime. However, it is important to note that osteoporosis is not solely an age-related condition and can also affect men and younger individuals.

Osteoporosis can be classified as primary or secondary.

  • Primary osteoporosis is primarily linked to the aging process and the decline in sex hormones, particularly estrogen in women.
  • Secondary osteoporosis arises from underlying medical conditions or certain medications. Conditions like hyperthyroidism, hyperparathyroidism, celiac disease, chronic kidney disease, and autoimmune disorders are known to increase the risk of osteoporosis. Medications such as glucocorticoids, some anti-epileptics, chemotherapy agents, proton pump inhibitors, and others have also been linked to osteoporosis.

Several risk factors can contribute to osteoporosis, some modifiable and others non-modifiable.

Non-modifiable risk factors include:

  • History of fracture in adulthood or in a first-degree relative
  • White race
  • Advanced age/Dementia/Fragility
  • Female sex

Modifiable risk factors include:

  • Current cigarette smoking
  • Low BMI
  • Early menopause (less than 45 years old) or bilateral oophorectomy and prolonged premenopausal amenorrhea (for more than a year)
  • Low dietary calcium intake
  • Alcoholism
  • Recurrent falls
  • Inadequate physical activity

Diagnosing osteoporosis typically involves a combination of medical history review, physical examination, and diagnostic tests.

Medical History and Physical Examination: A comprehensive history and physical examination can help identify potential risk factors for osteoporosis and osteoporotic fracture. Patients should be asked about their medical history, medication use, lifestyle habits (including smoking and alcohol consumption), and any history of previous fractures. Physical examination may reveal signs of advanced osteoporosis, such as loss of height and kyphosis (a curvature of the spine).

Diagnostic Tests:

  • Dual-energy X-ray absorptiometry (DEXA) scan: The gold standard for diagnosing osteoporosis. It measures bone mineral density (BMD) in the hip and spine and provides T-scores and Z-scores to assess bone health. The World Health Organization (WHO) defines osteoporosis as a T-score of -2.5 or lower.
  • The T score compares the current bone density to that of a younger age group and Z compares it to the average at the same age.
  • Laboratory tests: Assessing levels of calcium, phosphorus, vitamin D, thyroid function, and renal function can help rule out secondary causes of osteoporosis.
  • X-rays: Can identify fractures and provide clues about bone density.
  • Other imaging tests (CT scans, MRI, bone scans): May be used to evaluate fractures and rule out other conditions.

The primary goals of osteoporosis management are to prevent fractures, preserve bone density, and alleviate pain. Treatment strategies typically involve a combination of lifestyle modifications and pharmacological interventions.

Lifestyle Modifications:

  • Smoking cessation: Smoking is a significant risk factor for osteoporosis and should be avoided.
  • Regular exercise: Weight-bearing exercises, strength training, and balance exercises are crucial for maintaining bone health.
  • Adequate calcium and vitamin D intake: Ensuring sufficient intake of calcium and vitamin D through diet or supplementation is essential.
  • Fall prevention: Implementing strategies to minimize the risk of falls, such as home modifications and assistive devices, is crucial for preventing fractures.

Pharmacological Therapy:

  • Bisphosphonates: The first-line treatment for osteoporosis. These medications work by inhibiting bone resorption and increasing bone density. Examples include alendronate, risedronate, and zoledronic acid. Zolendronic acid is usually given as a yearly intravenous infusion and has to be accompanied by calcium supplementation. There is a risk of fever and body pains following administration which may be present for 3-4 days and usually self-limiting.
  • Denosumab: A monoclonal antibody that inhibits bone resorption and is an alternative to bisphosphonates, particularly for patients with poor renal function. Again given as a 6 monthly injection and can be continued for upto 10 years. This antibody binds to a particular receptor called RANKL and prevents bone loss.
  • Teriparatide and Abaloparatide: Anabolic agents that stimulate bone formation and are typically reserved for patients with severe osteoporosis or those who have not responded to other treatments. This is the only medication known to INCREASE bone formation and therefore is limited to a 2 year use. It is available as a metered dose syringe that can be self administered.
  • Selective estrogen receptor modulators (SERMs), such as Raloxifene: May be considered for postmenopausal women who cannot tolerate bisphosphonates or denosumab and have an increased risk of invasive breast cancer.
  • Hormone replacement therapy (HRT): Can be an option for women in early menopause, but its use should be carefully considered due to potential risks.
  • Calcitonin: May help reduce vertebral fractures, but long-term safety is a concern. Commonly it is used in case of acute fractures as an add on for early pain relief.

    Early detection and treatment of osteoporosis are crucial for preventing fractures and maintaining bone health. However, if left untreated, osteoporosis can lead to chronic pain, disability, loss of independence, and increased mortality risk.

    The most serious complication of osteoporosis is pathological fractures, particularly in the hip and spine. Hip fractures are associated with a significant increase in mortality risk, especially in older individuals. Vertebral fractures can cause chronic back pain, kyphosis, loss of height, and respiratory problems.

    In terms of education, the following guidelines are often advised.

    • Maintaining a healthy lifestyle: This includes a balanced diet rich in calcium and vitamin D, regular exercise, smoking cessation, and moderate alcohol consumption.
    • Understanding risk factors: Patients should be informed about the risk factors for osteoporosis and encouraged to discuss their individual risk with their healthcare provider.
    • Early detection and treatment: Regular bone density screenings are recommended for individuals at risk, and prompt treatment should be initiated if osteoporosis is diagnosed.

    Osteoporosis is a complex yet common condition that has far reaching impact on health and lifestyle especially in older women. The prevention is however, fairly straight forward but involves proactive identification by doctors and relevant advice regarding diet, exercise and regular monitoring.

    In addition, pharmacological interventions are mandated in patients with significant bone loss and who have a high fall risk to prevent additional morbidity and mortality.

    Ref. – Stat Pearls – National Library of Medicine

    Osteoporosis
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